Male Hormone Self Assessment - HARRIS INTEGRATED HEALTH AND NUTRITION

HARRIS INTEGRATED HEALTH AND NUTRITION

Welcome
Paperwork
Programs
- Eye to Eye >
- From a Distance >
Diet Lifestyle Environment
Resources
Cancer
- Cancer

Male Hormone Self-Assessment

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW

* Indicates required field

Name *

First

Last

Phone Number *

Today's Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Height *

Email *

Weight *

Marital Status *

Date of Birth *

Number of Children *

General Information Male Reproductive Male Genital Health

Male Hormone Self Assessment *

Have a history of antibiotic use Continuously use prescription medication Take synthetic hormones in a topical cream, patch or orally Have prostate problems Experience difficulty sleeping Experience mood swings Experience low libido Drink more than one glass of alcohol weekly Drink caffeine daily Experience exhaustion Experience low sperm count Experience penile erectile dysfunction Experience infertility Experience frequent urination

Male Hormone Self Assessment (cont) *

Prostate trouble Urination difficulty or dribbling Frequent night urination Pain on inside of legs or heels Leg nervousness at night Feeling of incomplete bowel evacuation Tire easily/avoid activity Reduced sex drive Depression Migrating aches and pains Frequent or urgent need to urinate delayed, weak or interrupted urinary stream Pain or burning upon urination Urge to urinate several times a night Rose colored (bloody) urine Difficulty urinating A sense of bladder fullness ejaculation causes pain Blood in the semen Lack of sex drive Impotency Pain or fatigue in the legs or back Dripping after urination Increased straining with small amounts of urine Anemia Current prostate enlargement or elevated PSA levels

Male Hormone Self Assessment (cont) *

Itchy patches around inner thigh or groin Itching at night Painful testicles Difficulty attaining and/or maintaining an erection Low sexual drive Premature ejaculation Low energy level or stamina Inflammation on the head of the penis Genital and/or rectal rash or irritation Distorted nail growth Loss of pubic or armpit hair Infertile Low sperm count, low sperm motility Unexplained weight gain Testicles appear smaller Development of breasts or nipple tenderness feeling of heaviness or hardness in testicles Sparse beard or slow hair growth Decreased body hair Fine wrinkling in corner of mouth and/or eyes Current or recurrent epididimis

Submit

Welcome
Paperwork
Programs
- Eye to Eye >
- From a Distance >
Diet Lifestyle Environment
Resources
Cancer
- Cancer